Copays are flat-dollar cost-sharing amounts that are popular because they are easily understood by members. Generics continue to have the lowest average retail 30 copay ($10) while specialty drugs average a much higher copay than other drugs at $84 (Figure 20). While up to three times as much days supply can be dispensed in a retail 90 claim, retail 90 copays were about 2.5 times greater than retail 30 copays for generics, preferred, and nonpreferred brands (Figure 21). Specialty drug copays in retail 90 averaged 2.1 times greater than retail 30 copays.
Consistent with the slowing prescription trend, retail 30 copay increases were relatively flat from 2010 to 2011 (Figure 22), with the exception of specialty, which increased 37% from $61 in 2010 to $84 in 2011. The large copay growth for specialty is a reflection of plan sponsors adding a fourth tier with higher copays for specialty in an effort to keep pace with growing specialty costs, which increased by 17% in 2010 (Source: Medco Drug Trend Report, 2011). The differential between the copay for the preferred and nonpreferred brands, a key determinant of market share movement for formulary drugs, was $20 in 2011. This differential has steadily grown from an average of $13 in 2000 as plan sponsors become more knowledgeable about the differential copays required to affect member choice. Similarly, the copay differential between the preferred brand and generic has increased from an average of $7 in 2000 to $16 in 2011 (Figure 23).
The largest range in copays across employers was observed for specialty, with the lowest copay being $10 and the highest being $250 (Table 16). This large range likely reflects differing philosophies to cost-sharing for specialty, one being that cost-sharing should keep pace with the cost of the medications as with other classes; and the second being that it is important to keep specialty copays as low as possible to minimize cost-related medication non-adherence. While some studies have been published on price sensitivity to specialty medications, there is still uncertainty about the optimal copay for specialty medications.
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